Information Collection

MUH Operator Baseline Survey

IC 204422 under ICR 201210-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MUH Operator Baseline Survey	Form
MUH Operator Baseline Survey Att 6A(e) Baseline Operator Survey_8 30 2012.doc	Form
Att 6A-2_MUH Operator Survey Consent MN ME FL.docx Survey Consent - MN, ME, FL	IC Document
Att 6A-1_LMUH Operator Survey Consent LA.docx Survey Consent - LA	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	MUH Operator Baseline Survey	Att 6A(e) Baseline Operator Survey_8 30 2012.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 136

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	136	136
Annual IC Time Burden (Hours)	170	170
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Consent - MN, ME, FL	Att 6A-2_MUH Operator Survey Consent MN ME FL.docx	09/24/2012
Survey Consent - LA	Att 6A-1_LMUH Operator Survey Consent LA.docx	09/24/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.